The New HIS Measures. Holly Swiger PhD, MPH, RN. CAHSAH Annual Conference & Home Care Expo April 25 27, 2017 Rancho Mirage, CA

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1 The New HIS Measures Holly Swiger PhD, MPH, RN 1

Objectives Review the current HIS reporting requirements Understand he two new quality measure details Explain the four new HIS discharge data

2 Objectives Review the current HIS reporting requirements Understand he two new quality measure details Explain the four new HIS discharge data items 3 HQRP Hospice Quality Reporting Program is mandated by Section 3004(c) of the Affordable Care Act of 2010 Pay for reporting Public reporting 4 2

3 HQRP Since Fiscal Year (FY) 2014, the Secretary shall reduce the Annual Payment Update (APU) by 2% for a hospice that does not comply with the quality data submission 5 HIS Data Submission Requirements 6 3

4 HQRP Reporting Requirements To comply with FY 2019 requirements, hospice providers must: Submit at least 80% of all Hospice Item Set (HIS) records within 30 days of the event (patient s admission or discharge) for admissions & discharges occurring 1/1/17 to 12/31/17 Have an ongoing monthly participation in the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey by an approved third-party vendor, whom submits data quarterly 7 Reporting Requirements All Medicare hospice providers with active CNN number (provider number) must report Hospices awaiting certification will be expected to have HIS processes in place at the time of their initial survey for deemed status Must report both admission and discharge HIS reports for all admissions 8 4

5 Reporting Requirements Providers are required to begin reporting data on the date noted on their CCN notification letter. However, if the CCN notification letter was dated on or after November 1st, they would not be subject to any financial penalty for failure to comply with HQRP requirements for the relevant reporting year. CMS HIS Q & A October Reporting Requirements HIS data is collected and submitted on all patient admissions, regardless of the patient s: Payer Age Location of receipt of hospice services (home, NF, ALF, GIP) Length of stay Transfers from another hospice 10 5

Flowchart for Patient Admission 11 Data Collection HIS data can be collected: By the assessing clinician in conjunction with patient assessment activities By

6 Flowchart for Patient Admission 11 Data Collection HIS data can be collected: By the assessing clinician in conjunction with patient assessment activities By abstraction from the patient s clinical record Data can be collected/abstracted by one or more members of the hospice team: Nurse Social Worker Aide Volunteer 12 6

7 HIS Review A review must be completed to ensure completeness of the entire HIS Individuals who completed any part of the HIS must sign in Z0400 Attesting to accuracy Individuals who review for completeness must sign Z0500 Only attesting to completeness Not attesting to accuracy of other hospice team members responses 13 Data Collection Hospices submit HIS data to CMS through the Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system. 14 7

8 HIS Data Submission To submit records into the QIES ASAP system, Hospice providers need: CMSNet User ID and password. Juniper software installed. QIES User ID and password. HIS record in the proper electronic file format. 15 HIS Recommended Completion & Submission Deadlines Admission HIS HIS Admission Recommended Completion Deadline = Admission Date + 14 calendar days (Admission day = day 0) Discharge HIS (Due to Death, Discharge or Revocation) HIS Discharge Recommended Completion Deadline = Discharge Date + 7 calendar days (Completion of abstraction of HIS within 7 days of discharge) HIS Admission Record Submission Deadline = Admission Date + 30 calendar days HIS Discharge Record Submission Deadline = Discharge Date + 30 calendar days 16 8

9 Data Submission Timelines HIS Records SUBMITTED does not mean that the HIS Records are ACCEPTED!! All HIS Records must be successfully accepted by the QIES ASAP system within 30 calendar days of the event date 17 HIS Final Validation Reports The FVR is available in the Validation Report folder in the CASPER Reporting application. A link to the CASPER Reporting application is available on the Welcome to the CMS QIES Systems for Providers Web page. 18 9

HIS Submission Threshold Calculation 19 HIS Quality Measures NQF NQF #1641 NQF #1647 NQF #1634 NQF #1637 NQF #1639 NQF #1638 NQF #1617 Measure Name Treatment Preferences Beliefs/Values Addressed (if

10 HIS Submission Threshold Calculation 19 HIS Quality Measures NQF NQF #1641 NQF #1647 NQF #1634 NQF #1637 NQF #1639 NQF #1638 NQF #1617 Measure Name Treatment Preferences Beliefs/Values Addressed (if desired by patient) Pain Screening Pain Assessment Dyspnea Assessment Dyspnea Treatment Patients Treated with an Opiod who are Given a Bowel Regimen NA Hospice & Palliative Care Composite Process Measure Comprehensive Assessment at Admission NA Hospice Visits When Death is Imminent Measure Pair20 10

11 Admission HIS 21 New Items for the Admission HIS Required for Admissions on or after 4/1/ A0550: Zip code 2. A1400: Payor Information 3. J0905: Pain Active Problem 4. Hospice and Palliative Care Quality Composite Measure 22 11

12 Current Issues on Identification of Administrative Information 23 Current Issues on Identification of Administrative Information Use the name as it appears on the Medicare Card 24 12

13 New Item on Identification of Administrative Information 25 Current Issues on Identification of Administrative Information Check all that apply, according to the patient/family! 26 13

Current Issues on Identification of Administrative Information 27 Payor Information Response J Self Pay: Should be selected if the patient has any amount of personal funds available to contribute to

14 Current Issues on Identification of Administrative Information 27 Payor Information Response J Self Pay: Should be selected if the patient has any amount of personal funds available to contribute to healthcare expense Response K No Payor Source: Should be selected if the patient does not have any of the payor sources in response to options A-I available, nor do they have any personal funds available to contribute to healthcare expenses. 14

15 Payor Information Response X Unknown: Should be selected if the patient is not confirmed to have any of the above payor sources in response options A-K Response Y Other: Should be selected if the patient has available one or more payor sources that is not listed in response options A-K. NQF #1641 Treatment Preferences Numerator Patient stays from the denominator where the patient/responsible party was asked about preference regarding use of cardiopulmonary resuscitation, or hospitalization, or other life-sustaining treatments no more than 7 days prior to admission or within 5 days of the admission date. Denominator - All patient stays, except those with exclusions. Patients under 18 are excluded

16 Current Issues in Section F: Preferences Scenario 1 Date of Admission 7/1/16 7/1/16 Clinical record for the patient includes a DNR order, signed by patient 6/15/16. Scenario 2 - Date of Admission 7/1/16 7/3/16 Nurse assessment checked box, Patient wants comfort care. 31 Current Issues in Section F: Preferences Scenario 3 Date of Admission 7/1/16 7/1/16 Nurse Assessment Note states, Talked with patient and caregiver about preferences for readmission to hospital. Patient was hesitant and said they weren t sure. Told patient that we could discuss this further on a future visit

NQF #1641 Beliefs/Values Addressed Numerator Number of patient stays from the denominator where the patient and/or caregiver was asked about spiritual/existential concerns no more than 7 days prior

17 NQF #1641 Beliefs/Values Addressed Numerator Number of patient stays from the denominator where the patient and/or caregiver was asked about spiritual/existential concerns no more than 7 days prior to admission or within 5 days of the admission date. Denominator - All patient stays, except those with exclusions. Patients under 18 are excluded. 33 Current Issues in Section F: Beliefs/Values Addressed Scenario 1 Date of Admission 8/1/16 SW Assessment Note dated 8/2/16 Patient s spouse in a great deal of spiritual distress and wants to speak with chaplain. Referral made. Scenario 2 - Date of Admission 8/1/16 Nurse Assessment Note dated 8/1/16 Patient identified as Baptist

Current Issues in Section I: Active Diagnoses Do not use external sources for your response This is your hospice primary diagnosis Even if your primary diagnosis changes during their stay on hospice,

18 Current Issues in Section I: Active Diagnoses Do not use external sources for your response This is your hospice primary diagnosis Even if your primary diagnosis changes during their stay on hospice, you do not update this 35 NQF #1634 Pain Screening Numerator - Patient stays from the denominator who are screened for the presence or absence of pain and, if present, rating of its severity using a standardized tool within 2 days of admission to hospice. Denominator - All patient stays except for those with exclusions. Patients under 18 are excluded

19 Current Issues in Section J: Health Conditions 37 Types of Standardized Pain Tool Utilized Numeric Examples of standardized numeric scales include but are not limited to, 10- point scale, the Symptom Distress Scale (McCorkle), the Memorial Symptom Assessment Scale (MSAS), and the Edmonton Symptom Assessment System (ESAS). Verbal Descriptor Examples of standardized verbal descriptor scales include, but are not limited to, the Brief Pain Inventory, the McGill pain questionnaire, and the 6- Point Verbal Pain Scale

20 Types of Standardized Pain Tool Utilized Patient Visual - Examples of standardized patient visual scales include, but are not limited to, the Wong- Baker FACES Pain Scale, a visual analog scale, and a distress thermometer. Staff Observation - Examples of standardized staff observation scales include, but are not limited to, the Critical Care Pain Observation Tool (CPOT), the Checklist of Nonverbal Pain Indicators (CNPI), the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC), and Pain Assessment in Advanced Dementia (PAIN-AD). 39 Current Issues in Section J: Health Conditions 40 20

21 Pain Active Problem (J0905) All patients should be screened for pain. Should be in the initial assessment and be based on patient specific findings. If pain is identified at the time of admission or as an active problem there should be a comprehensive assessment. What Qualifies as an Active Pain Problem? Consider factors beyond pain severity at the time of the encounter: Historical report of pain or reports of recent symptoms Current treatment for pain with scheduled or prn medications It is possible that the clinician may determine pain is an active problem for the patient, even if pain is not present during the clinical encounter. 21

E-Kit What Qualifies as an Active Pain Problem? Comfort Kits and pre-printed admission orders alone are insufficient evidence to determine pain is an active problem.

22 E-Kit What Qualifies as an Active Pain Problem? Comfort Kits and pre-printed admission orders alone are insufficient evidence to determine pain is an active problem. Treatment is not considered initiated until there is an order and there is documentation that the patient/caregiver was instructed to begin using the medication. Pro-active education on medications in a comfort kit in anticipation of symptoms alone is insufficient evidence to determine pain is an active problem. Old Version of Pain Screening 44 22

New J0900 Pain Screening Revised Sequence NQF #1637 Pain Assessment Numerator - Patient stays from the denominator who received a comprehensive pain assessment within 1 day of the pain screening and

23 New J0900 Pain Screening Revised Sequence NQF #1637 Pain Assessment Numerator - Patient stays from the denominator who received a comprehensive pain assessment within 1 day of the pain screening and the pain assessment included at least 5 of the following characteristics: location, severity, character, duration, frequency, what relieves or worsens that pain, and the effect on function or quality of life. Denominator - Patients stays, except for those with exclusions, where the patient s pain severity at the pain screening was rated mild, moderate, or severe. Patients under 18 are excluded

Comprehensive Pain Assessment For inclusion in the new composite measure: 1. If applicable, a comprehensive pain assessment must occur within 1 day of the positive pain screen, and 1.

24 Comprehensive Pain Assessment For inclusion in the new composite measure: 1. If applicable, a comprehensive pain assessment must occur within 1 day of the positive pain screen, and 1. Include at least five of the seven pain characteristics. Comprehensive Pain Assessment for Non-Verbal Patients A caregiver report about any of the above characteristics is acceptable. Clinical notes about assessment of nonverbal indicators of pain for any of the above characteristics are also acceptable

25 Comprehensive Pain Assessment for Non-Verbal Patients Nonverbal indicators of pain include nonverbal sounds such as crying, whining, and groaning; facial expressions, such as grimacing and clenching jaws; and protective body movements or postures such as bracing, guarding, rubbing, or clutching a body part. For example: An assessment that included pain location for a nonverbal patient may include documentation, such as patient grimaced and shouted when clinician touched their right leg or other documentation denoting patient exhibiting nonverbal cues of pain for a specific location on the body. 49 Comprehensive Pain Assessment for Non-Verbal Patients - An assessment that included pain severity for a nonverbal patient may include documentation about intensity of nonverbal expressions of pain (grimaces, winces, and clenched teeth/jaw) or protective body movements (bracing, guarding, rubbing, clutching, or holding of a certain body part/area). It could also include documentation of severity using a nonverbal standardized rating scale. - Character will not be able to be assessed on a patient as it is a descriptor by the patient

26 Comprehensive Pain Assessment for Non-Verbal Patients - An assessment that included pain duration for a nonverbal patient may include documentation about how long a patient exhibits any nonverbal cues of pain, such as patient cradled right arm throughout entire visit. - An assessment that included pain frequency for a nonverbal patient may include documentation about how often a patient exhibits any nonverbal cues of pain, such as most of the time, only at night, intermittently. 51 Comprehensive Pain Assessment for Non-Verbal Patients An assessment that included what relieves/worsens pain for a nonverbal patient may include documentation about actions, activities, or positions that relieve/worsen pain, such as patient exhibits fewer nonverbal signs of pain when sitting up versus lying down. An assessment that included pain s effect on function or quality of life for a nonverbal patient may include documentation about change in patient activity, such as family caregiver reports that patient is no longer able to sit up in bed without moaning

27 Comprehensive Pain Assessment for Non-Verbal Patients For any of the seven characteristics included in the pain assessment, select response options based on whether the clinician made an attempt to gather the information from the patient/caregiver. For example, if, for a nonverbal patient, the clinician asked the family/caregiver about pain location and the family/caregiver responded I m not sure or I don t know, 1, Location should be checked for J0910C because the clinician attempted to gather the information. 53 NQF #1639 Dyspnea Screening Numerator Percentage of patient stays during which the patient was screened for dyspnea during the initial nursing assessment. Denominator - All patient stays except for those with exclusions. Patients under 18 are excluded

28 Current Issues in Section J: Health Conditions Respiratory Status Always have a reason to answer YES! Always assess!!! 55 Current Issues in Section J: Health Conditions Respiratory Status Scenario 1 3/5/17 Clinical Note Patient very drowsy; appears to be comfortable during visit. Scenario 2 3/5/17 Clinical Note Patient reports no discomfort and is breathing shallowly but without signs of distress; no concerns about breathing from patient or family

NQF #1638 Dyspnea Treatment Numerator Patient stays from the denominator who received treatment within 1 day of screening positive for dyspnea.

29 NQF #1638 Dyspnea Treatment Numerator Patient stays from the denominator who received treatment within 1 day of screening positive for dyspnea. Denominator - Patient stays, except those with exclusions, where the patient screened positive for dyspnea at the initial screening encounter. Patients under 18 are excluded. 57 Current Issues in Section J: Health Conditions Dyspnea Treatment 58 29

NQF #1617 Bowel Regime for Opioids Numerator Patients from the denominator that are given a bowel regimen or there is documentation as to why this was not needed.

30 NQF #1617 Bowel Regime for Opioids Numerator Patients from the denominator that are given a bowel regimen or there is documentation as to why this was not needed. Denominator - Patient stays, except for those with an exclusion, where a scheduled opioid that is initiated or continued. Patients under 18 are excluded. 59 Current Issues in Section N: Medications 60 30

31 Current Issues in Section N: Medications 61 Current Issues in Section N: Medications This is only if the patient has a scheduled or prn opioid ordered. Don t forget treatments such as non pharmaceutical measures such as increasing fluids, prune juice, etc

Current Issues in Section N: Medications Scenario 3/24/17 Orders Oxycodone 10 mg PO every 4 hours, PRN for pain. 3/24/17 Clinical Note Patient has diarrhea.

32 Current Issues in Section N: Medications Scenario 3/24/17 Orders Oxycodone 10 mg PO every 4 hours, PRN for pain. 3/24/17 Clinical Note Patient has diarrhea. 63 Composite Process Measure Comprehensive Assessment at Admission Active for Discharges on or after 4/1/2017 Numerator All patient stays from the denominator who meet the numerator criteria for the individual component QMs applicable to the patient. Denominator - All patient stays, except for those with exclusions. Patients under 18 are excluded

33 Hospice and Palliative Care Composite Process Measure This measure will provide consumers and providers with: A single measure regarding the overall quality and completeness of assessment of patient needs at hospice admission. A measure that can be used to meaningfully and easily compare quality across hospice providers. A measure that sets a higher standard of care for hospices. Hospice and Palliative Care Composite Process Measure This Quality Measure reports the percentage of hospice patients who received all seven HIS care processes for which they are eligible at admission to a hospice. The measure is calculated using data from existing HIS-Admission items. No new data collection will be required for this measure. Patient admissions occurring on or after April 1, 2017, will be included in the measure calculation. 33

Hospice and Palliative Care Composite Process Measure Hospice and Palliative Care Composite Process Measure Exclusions: Discharge data with no admission data Patients Under 18.

34 Hospice and Palliative Care Composite Process Measure Hospice and Palliative Care Composite Process Measure Exclusions: Discharge data with no admission data Patients Under 18. Data will still be collected, but will not be calculated in the composite score. A major change to the measure specifications as part of the NQF endorsement was removal of the length of stay (LOS) criterion; all seven measures now have no LOS exclusion. 34

35 Discharge HIS 69 Discharge HIS Active for Discharges on or after 4/1/2017 Section O: Service Utilization (Hospice Visits When Death is imminent) CMS goal of increasing care in the last week of life and eventually reporting it publically

36 Section O: Service Utilization Paired Measure #1 Numerator Number of patients from the denominator receiving at least one visit from registered nurses, physicians, nurse practitioners or physician assistants in the last 3 days of life. Denominator - All patients, except for those with exclusions. Patients are excluded from the denominator if the patient did not expire in hospice care or the patient received any continuous home care, respite care, or general inpatient care in the last 3 days of life. 71 Discharge Quality Measures Applies to patients discharged due to death. Patients who had GIP, CC or Respite during the period of review are excluded. Phone calls are not counted. Post-Mortem visits are not counted. Visits provided to the patient s family may be counted. Patients under 18 are not excluded. 36

disciplines: Registered Nurses Physicians Nurse

37 Visits in the Last 3 Days of Life Assesses the percentage of patients receiving at least one visit from the following disciplines: Registered Nurses Physicians Nurse Practitioners or Physician Assistants Visits in the Last 3 Days of Life 37

38 Section O: Service Utilization Paired Measure #2 Numerator Number of patients from the denominator receiving at least two visits from medical social workers, chaplains or spiritual counselors, licensed practical nurses or hospice aides in the last 7 days of life. Denominator - All patients, except for those with exclusions. Patients are excluded from the denominator if the patient did not expire in hospice care or the patient received any continuous home care, respite care, or general inpatient care in the last 7 days of life, or had a length of stay of one day. 75 Visits in the Last 7 Days of Life Assesses the percentage of patients receiving at least two visits from the following disciplines: Medical Social Workers Chaplains or Spiritual Counselors LVNs Hospice Aides 38

39 Section O: Service Utilization Paired Measure #2 77 Section O: Service Utilization Paired Measure #

40 Section O: Service Utilization Paired Measure #2 Three days prior to death is calculated as A0270 (Discharge Date) minus 3. Four days prior to death is calculated as A0270 minus 4. Five days prior to death is calculated as A0270 minus 5. Six days prior to death is calculated as A0270 minus

41 Section Z: Record Administration 81 Section Z: Record Administration 82 41

CASPER Hospice Level Quality Measure Report 83 HIS Collection & Submission Who will be doing the abstraction? Will it be individual staff, QAPI staff, managers?

42 CASPER Hospice Level Quality Measure Report 83 HIS Collection & Submission Who will be doing the abstraction? Will it be individual staff, QAPI staff, managers? Who will be responsible to review for completeness and sign the Z0500? Who will submit the data? Who will review the Final Validation Report and follow up on Fatal Errors or Rejected Records? 84 42

43 HIS Summary Know & meet the timelines for completion & submission Ensure that staff complete all 7 assessments Reinforce confusing areas and teach new HIS data to be collected Be sure your EMR calculations are correct Report in XML format Track you re HIS data in Casper Follow the CMS Quarterly HIS Q & As 85 References FY 2017 Hospice Final Rule: The Hospice Item Set Manual: Assessment-Instruments/Hospice-Quality-Reporting/Hospice- Item-Set-HIS.html. Hospice Quality Reporting: Assessment-Instruments/Hospice-Quality- Reporting/index.html. 43

44 Resources Hospice User Guides and Training: CMS HQRP Website: PatientAssessment-Instruments/Hospice- QualityReporting/index.html Quality Help Desk: Technical Help Desk or (877) (Monday-Friday 7:00 a.m. - 7:00 p.m. Central Time) 87 Listservs: Resources MLN Connects enews ubscriber/new?pop=t&top ic_id=uscms_7819 ODF listserv HHHDME.html Federal Register: Review proposed and final rules 88 44

45 Thank You! Questions? 89 Session Sponsor Visit Sponsor at Booth # 112! 90 45

46 Speaker Information Holly Swiger PhD, MPH, RN Owner/Lead Consultant Stellar Concepts, Inc Sky High Drive

Overview HOSPICE QUALITY REPORTING PROGRAM (HQRP) 10/10/2016

Overview HOSPICE QUALITY REPORTING PROGRAM (HQRP) 10/10/2016 Hospice Quality Reporting Requirements and Using Reports in Your QAPI Program Octobe Overview Identify the current and 2017 CMS Hospice Quality Reporting Requirements. Identify the financial risk of failure